Levente Gáspár

Mosaicplasty for the treatment of osteochondritis dissecans of the talus: Two to seven year results in 36 patients

An osteochondral defect (OCD) is known as a symptomatic lesion causing pain, recurrent synovitis, and altered joint mechanics most commonly in a weightbearing joint. Loose bodies may develop, which may then cause joint destruction and/or locking. The damage to the articular surface is most likely a precursor of ankle osteoarthritis. With the recent advances in diagnostic imaging, such as MRI, as well as the development of ankle arthroscopy, the identification and classification of these lesions has become much more precise. This allows more accurate staging and improves treatment recommendations. The assessment of a particular treatment is also improved. A variety of treatment alternatives are now available. These include arthroscopic procedures including debridement, retrograde drilling, and bone grafting. Compared to open treatment, arthroscopic procedures may be particularly advantageous in the treatment of small defects and stable OCD lesions. Until recently, however, favorable results have been less predictable for large or unstable osteochondral defects. We treat these more difficult lesions with a mosaic autogenous osteochondral transplantation. In our hands, this appears to provide an optimal treatment result. The present report evaluates the clinical outcome of 36 patients followed for two to seven years after a mosaicplasty autogenous osteochondral transplantation from a non or less weight bearing portion of the knee to the ipsilateral talus. Ankle function was measured by the Hannover scoring system and showed good to excellent results in 34 cases (94%) with no long term donor site morbidity. The encouraging clinical results are supplemented with radiographs and histology, which support the premise of lasting relief of symptoms and prevention of ankle arthrosis.

Angiogenesis in rheumatoid arthritis.

Angiogenesis is the formation of new capillaries from pre-existing vessels. A number of soluble and cell-bound factors may stimulate neovascularization. The perpetuation of angiogenesis involving numerous soluble and cell surface-bound mediators has been associated with rheumatoid arthritis (RA). These angiogenic mediators, among others, include growth factors, primarily vascular endothelial growth factor (VEGF) and hypoxia-inducible factors (HIFs), as well as pro-inflammatory cytokines, various chemokines, matrix components, cell adhesion molecules, proteases and others. Among the several potential angiogenesis inhibitors, targeting of VEGF, HIF-1, angiogenic chemokines, tumor necrosis factor-alpha and the alpha(V)beta(3) integrin may attenuate the action of angiogenic mediators and thus synovial angiogenesis. In addition, some naturally produced or synthetic compounds including angiostatin, endostatin, paclitaxel, fumagillin analogues, 2-methoxyestradiol and thalidomide may be included in the management of RA.

Thrombotic and fibrinolytic alterations in the aseptic necrosis of femoral head

&NA; Recent reports seem to support the role of the thrombophilia and decreased fibrinolysis in the aetiopathogenesis of aseptic necrosis of bone. In the present study, haemostatic disturbances were analysed in adults (n = 49) and patients in childhood (Perthes disease) (n = 47) with aseptic necrosis of the femoral head. Fibrinolytic parameters (in vitro clot lysis, plasminogen, plasmatic plasminogen activator inhibitor‐1 activity, D‐dimer) along with lipoprotein (a) [Lp(a)] and fibrinogen were measured. von Willebrand factor, platelet activation and some thrombophilic factors (activated protein C resistance and factor V Leiden mutation, protein C, protein S activity) were also determined. Impaired fibrinolysis, an increased Lp(a) level along with slow clot lysis and increased platelet activation were found in adult cases. We detected five cases of factor V Leiden mutations (one heterozygotic and four homozygotic) among patients with Perthes disease. The clinical course of the heterozygous case was similar to the usual form of Perthes disease. The most severe form of Perthes disease has been observed in homozygous factor V Leiden mutation cases. The mutation of factor V Leiden per se probably does not induce the development of aseptic necrosis of bone tissue in childhood, but it does play a role in its acceleration. Homozygous factor V Leiden mutation definitely runs a more severe course. On the other hand, in adult cases, the disturbances of haemostasis, impaired fibrinolysis, elevated Lp(a) level, increased platelet activation and slight elevation of fibrinogen might have clinical relevance. Further studies should focus on proving the role of the haemostatic alterations in the pathogenesis of severe forms of aseptic bone necrosis. The use of antithrombotic drugs in order to slow the process of aseptic necrosis also has to be addressed in future surveys. Blood Coagul Fibrinolysis 14:243‐248

Increased platelet activation and decreased fibrinolysis in the pathogenesis of aseptic necrosis of the femoral head.

Thrombotic events, increased tendency toward intravascular thrombosis and decreased fibrinolysis seem to be possible pathologic causes for aseptic necrosis of the femoral head (ANFH) in adults. This project was to study whether either increased platelet activation or decreased fibrinolytic activity and/or any other thrombogenic factor may be implicated in the evolvement of ANFH. The speed of the in vitro lysis was significantly lower in patients (both in primary and in secondary cases) compared with healthy controls. The platelet activation (measuring with beta TG) proved to be significantly higher in the primary group as well as in the secondary group compared with healthy controls. Lp(a) levels were elevated in primary and secondary cases. This alteration was more characteristic in the primary cases. Fibrinogen levels were also elevated in the primary group, but the difference was not significant. The data shown here may further support that hypofibrinolysis and increased thrombogenesis are major causes of ANFH. Early diagnosis of ANFH increases the chances of modifying the course of this disabling disease.

A complementary thoracic implant for the surgical correction of the scoliotic curve. A preliminary report

SummaryThe results of the surgical correction of scoliosis through posterior approach have significantly improved by the introduction of new implants during the past decades. Even with these improvements the available implants only allow limited correction especially regarding axial rotation, and also their application is rather complicated. We developed a new implant which simultaneously grasps and exerts forces on both transverse processes of the vertebrae, to achieve a more efficient and safer correction with a simple surgical technique. In our paper we report on the concept of the new implant, its most important features, its mechanical tests, cadaver experimentations, and biomechanical assessments.

Capsular neuronal elements and their relation to pain reduction and functional improvement following total hip replacement

We studied changes of pain intensity and functional impairment in 22 patients with osteoarthrosis undergoing total hip replacement. Using a visual analogue scale, the mean scores for pain and disability before surgery were 71.7 and 70.9 respectively. Both scores showed gradual improvement during a 1-year follow-up period, with more than 90% of the total improvement occurring within the first 3 months. After 1 year, the scores for pain and disability were 11.9 and 4.1 respectively. The hip joint capsule was studied using immunohistochemistry to detect neurofilaments. Neurofilament immunoreactivity was observed in 16/22 cases and was correlated with pain and disability scores. However, there were no correlations between pre- and postoperative pain scores, the score changes, and the quantity of capsular neurofilaments. Thus, other factors than capsular neurofilaments influence the scores of pain and disability in osteoarthritis.RésuméNous avons étudié les changements d’intensité de la douleur et les modifications fonctionnelles chez 22 malades ayant subit une prothèse totale de la hanche pour arthrose. Avec une échelle analogue visuelle, les scores moyens pour la douleur et l’invalidité avant la chirurgie étaient de 71.7 et 70.9 respectivement. Les deux scores ont montré l’amélioration graduelle pendant une année après l’opération, avec plus de 90% de l’amélioration totale dans les trois premiers mois. Après une année les scores pour douleur et invalidité étaient de 11.9 et 4.1 respectivement. La capsule articulaire a été étudiée par immunohistochimie pour détecter les neurofilaments. L’immunoréactivité des neurofilaments a été observé dans 16/22 cas et était corrèlée avec la douleur et le score de l’invalidité. Cependant, il n’y avait pas de corrélations entre les scores de la douleur pré- et postopératoire, la modification du score fonctionnel et la quantité de neurofilaments capsulaires. Il y a donc d’autres facteurs que les neurofilaments capsulaires qui influencent la douleur et l’invalidité dans l’arthrose.

Multilevel callus distraction: a novel idea to shorten the lengthening time

Lower extremity inequality is a common problem in everyday orthopaedic practice. The leg discrepancy can lead to variety of other problems, i.e., spinal problems. Surgical intervention is very demanding and requires patient compliance. Wagners and Ilizarovs elongation technique are most commonly used worldwide, but it gives satisfactory results only in a long period of time and as we know there could be several inconvenient outcomes. Our idea aims at shortening this time period, and avoiding some of the inconvenient outcomes. Unfortunately we do not have the opportunity to go further in our investigations, but we hope that someone interested in this field will have an idea which would make continuation possible.

Results of surgical treatment of knee instabilities

Between January 1, 1981 and January 5, 1987, 146 reconstructive operations for acute (39) and chronic (107) knee instabilities were performed. THe majority of the acute cases were anteromedial (24), and of the chronic instabilities, 33 were anteromedial, 14 anterolateral, and 53 combined anteromedial-anterolateral. In terms of suture, replacement, and reinforcement of the damaged structures of the acute cases, 32 were good, 6 fair, and 1 poor, while the reconstruction, according to Müller, for chronic instabilities produced good results in 34, fair in 59, and poor in 14. It is essential that such operations be performed by a trained surgical team. For success, precise knowledge of anatomy, exact examination, accurate diagnosis, adequate surgical techniques, and careful postoperative treatment are essential.